About two thirds of American adults report at least one type of childhood maltreatment or household dysfunction, and nearly 13% experienced four or more (Centers for Disease Control and Prevention, 2013). These numbers underestimate the rates of early adversity in poor, disadvantaged, clinical, and criminal populations, and in sex offender samples (Levenson, Willis, & Prescott, 2014). As adverse childhood experiences (ACE) accumulate, the risk for myriad health, mental health, and behavioral problems in adulthood also grows in a robust and cumulative fashion (Felitti, et al., 1998). Trauma-informed clinicians recognize the prevalence of trauma in the population, expect the majority of clients to have experienced early adversity, and understand the biological, social, psychological, cognitive, and relational impact of trauma on adult functioning and high-risk behavior.
Trauma-Informed Care (TIC) is a framework that is infused throughout a service delivery setting, and it embraces several crucial principles: It is client centered and provides a safe, trustworthy, consistent, validating, empowering environment, and promotes respect, compassion and self-determination (Bloom & Farragher, 2013; Harris & Fallot, 2001). TIC is not trauma resolution therapy. Rather, trauma informed therapists view presenting problems through the lens of early experiences, knowing that children often survive adversity by developing coping strategies that work well in traumogenic households but then become obstacles to healthy functioning in other (more “normal”) environments later in life. The question becomes not “what’s wrong with you?” but “what happened to you?” in understanding how maladaptive cognitive schema and behaviors evolved and became well-rehearsed across various domains of life. Trauma-informed clinicians infuse CBT models with relational interventions that utilize the counseling relationship itself as an opportunity to help clients develop attachments to healthy others, have corrective emotional experiences, and practice new skills (Levenson, 2014). Above all, TIC avoids replicating disempowering dynamics in the helping relationship, including confrontational approaches that reinforce the shame and marginalization that many of our clients endured in their own homes and communities.
TIC provides an innovative framework for facilitating change within a larger model of cognitive-behavioral sex offender therapy. TIC complements RNR principles which promote individualized treatment planning to match criminogenic needs, risk factors, motivation, and characteristics impacting the ability to embrace and engage in treatment (Andrews & Bonta, 2007, 2010). TIC also fits well with Good Lives Models that help clients attain self-actualization goals while improving affective and behavioral self regulation (Willis, Ward, & Levenson, 2013; Yates, Prescott,& Ward, 2012).
It is time for ATSA to start talking about TIC. For the past 25 years we have almost exclusively emphasized content-focused, offense-specific, skills-based relapse prevention programming. It is perhaps unsurprising that our treatment effectiveness studies have sometimes been disappointing. There are huge literatures that can inform our work: neurobiology of trauma, developmental psychopathology, ACE prevalence and impact on psychosocial outcomes, and the "common factors" of therapeutic alliance and engagement. Evidence-based practice is sometimes too narrowly defined as only those interventions which have shown effectiveness in randomized controlled trials. But EBP begins with building treatment programs that are informed by research in various areas. TIC approaches recognize the role of trauma in the development of problematic behavior, and might mitigate risk to re-offend as sex offender clients experience empowering relationships and learn to meet emotional needs in non-victimizing ways.
Jill S. Levenson, Ph.D., LCSW, Barry School of Social Work
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Centers for Disease Control and Prevention. (2013). Adverse Childhood Experiences Study: Prevalence of Individual Adverse Childhood Experiences. Retrieved from http://www.cdc.gov/ace/prevalence.htm
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., et al. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. American journal of preventive medicine, 14(4), 245-258.
Harris, M. E., & Fallot, R. D. (2001). Using trauma theory to design service systems. San Fransisco, CA: Jossey-Bass.
Levenson, J. S. (2014). Incorporating Trauma-Informed Care into Sex Offender Treatment. Journal of Sexual Aggression, 20(1), 9-22.
Levenson, J. S., Willis, G., & Prescott, D. (2014). Adverse Childhood Experiences in the Lives of Male Sex Offenders and Implications for Trauma-Informed Care. Sexual Abuse: A Journal of Research & Treatment. doi: 10.1177/1079063214535819
Willis, G. M., Ward, T., & Levenson, J. S. (2013). The Good Lives Model (GLM):: An Evaluation of GLM Operationalization in North American Treatment Programs. Sexual abuse: a journal of research and treatment.
Yates, P. M., Prescott, D., & Ward, T. (2012). Applying the good lives and self-regulation models to sex offender treatment: A practical guide for clinicians: Safer Society Press.